45,000 More Psychiatrists, Anyone?

Houston, we have a problem. There is a critical shortage of psychiatrists. And the problem is not in Houston alone-- it includes the entire state of Texas, and every other state in the union (Mid-town Manhattan, Boston-- Beacon Hill, and Sacramento Street in San Francisco might be exceptions).

According to the most recent of studies commissioned by the government, America is shy about 45,000 psychiatrists. And the shortage will get worse, because many psychiatrists are reaching retirement age.

Before commenting on possible solutions, let's get a better fix on where this rather astounding number comes from. After all, labor statistics are politically charged quantities because they are often used as ammunition for various stakeholders to win funding for pet programs. So it's important to be skeptical.

The underlying data were published as a series of 3 articles in the October 2009 issue of Psychiatric Services. The research was commissioned by the Health Resources and Services Administration and was done by researchers at the Cecil G. Sheps Center for Health Services Research at the University of North Carolina at Chapel Hill. Here I'll focus on the study by Konrad and colleagues,1 since it provides a good overview of the entire project. To facilitate ease of reading, I am not including all the references to other studies discussed in the original paper. I urge interested readers to peruse the original article for more details.

These researchers started with what they considered to be the most reliable recent estimates of the prevalence of mental illness in this country--the National Comorbidity Survey Replication (NCS-R) of 2001. That study was a random house-to-house survey of more than 9000 people. The authors did not want to simply use the NCS-R's figures at face value because that would have included many people whose mental illnesses are not particularly severe. Instead, they identified only those people who were functionally impaired and who had what they defined as "serious" mental illness--bipolar disorder, major depressive disorder, agoraphobia, generalized anxiety disorder, panic disorder, posttraumatic stress disorder, social phobia, or specific phobia.

You'll notice some glaring omissions here--most notably schizophrenia, substance abuse, and ADHD. Why weren't these included? There are various reasons, some having to do with the quality of the data they had to work with. The NCS-R data, oddly enough, did not include enough questions to reliably diagnose schizophrenia, so the researchers decided they could not come up with reliable prevalence numbers for schizophrenia. What about substance abuse? While the NCS-R data included substance abuse, there is little reliable data on how many substance abuse clinicians are out there, so they omitted this diagnosis from their analysis. And then there were a number of diagnoses the authors considered not serious enough to include--such as ADHD, conduct disorder, oppositional defiant disorder, dysthymia, and a few others.

The bottom line is that given the exclusion of many patients with disorders that required some kind of treatment, the study results are necessarily very conservative. Whatever shortage of services they discover will need to be amplified to make up for these uncounted patients. Nonetheless, using their particularly strict and conservative criteria, they estimated that the 1-year prevalence of "serious mental illness" in the US is 3.9%. The authors note that this estimate is very close to other recent estimates of the prevalence of significant disabling mental illness.

How much mental health treatment do these patients need? Using more data from NCS-R, the researchers stated that "about half of adults with serious mental illness used services; they typically spent 10.54 hours per year (95% confidence interval (CI), 5.46 to 15.63) with nonprescriber mental health professionals and 4.38 hours per year (CI, 3.40 to 5.37) with primary care physicians or prescriber mental health professionals."

Do these numbers sound right? Essentially, they are saying that patients with serious mental illness have about 1 therapy visit per month, and about 20 minutes per month of psychopharm-oriented visits with some prescriber. It sounds fairly realistic as an average, considering that some "stable" patients probably never see a therapist and just see their psychiatrist every 3 months or so for a medication refill, while on the other end of the spectrum, there are very ill patients who have at least weekly therapy sessions and biweekly psychopharmacological visits.

So how many mental health providers are needed? Now that the researchers estimated the number of patients with mental illness, the number of hours of care needed on average by each patient, and the amount of care provided by the average full-time clinician (I don't have the space to detail how they got that statistic, but it was derived from various surveys of practice patterns from the APA and other sources), they could calculate the bottom line--how many clinicians does the US need to treat its mentally ill citizens? They estimated that we need 25.9 psychiatrists per 100,000 population. This is an average number, which varies by county--typically, poorer people need more psychiatric time, so the need for help is greater in poorer counties.

The problem is that we only have roughly 10 per 100,000 practicing full-time psychiatrists in the US, or about 30,000 total. That's 15 per 100,000 too few, and assuming a population of about 300 million, we arrive at the estimated shortage of 45,000 psychiatrists. This is a very rough estimate to be sure--let's call it 45,000 plus or minus 15,000. Either way, it represents a mental health services crisis.

So--what are we going to do to solve this problem? I'm not sure, but here are some potential options:

1. Let's get the primary care physicians (PCPs) to absorb our excess patients. Sorry, but as family practitioner and writer Michael Victoroff once told me, "that donkey is overloaded already." PCPs are dealing with longer wait lists than psychiatrists and they are coping with a vast array of illnesses to manage. Outcomes research has shown that PCPs don't do the best job of treating psychiatric problems. For example, a recent study found that the mental health care dropout rate from PCPs was 32%--more than double the dropout rate from psychiatrists.2

These data are hardly surprising, since PCPs have barely enough time to hand out a pill and refer to a social worker, psychologist, or psychiatrist. And the psychiatrist will often be either unavailable or will refuse the patient's insurance.

2. Let's churn out more psychiatrists. That means expanding residency programs. That's a nice idea, but who is going to foot the bill? Medicare pays for the vast majority of residency slots in the US, and the going rate is upwards of $100,000 per slot. Is Medicare planning to shell out 45,000 3 $100,000 = $4.5 billion to solve the mental health access problem? Unlikely--in fact, we were lucky that President Obama's health care reform package is allocating $168 million to create only 600 more primary care physician residency slots. Most psychiatry residency directors feel lucky if they can simply hold on to the reimbursed positions they have now.

3. Let's train more advanced practice nurses and physician assistants. That might work over the long term, because the economics are more feasible. Physician extenders' training is shorter and less expensive, their incomes are lower, and they typically are more likely to work for underserved populations. One problem: they get very little training in psychology or psychotherapy--limiting their ability to properly diagnose and treat tough cases.

4. Let's give medically trained psychologists prescriptive authority. Though unpopular among psychiatrists, this is an increasingly viable solution. Psychologists with 2-year psychopharmacology masters degrees have been prescribing safely for 20 years in the military and for slightly less than a decade in New Mexico and Louisiana. (For a thorough review of this issue, see the recently published book Pharmacotherapy for Psychologists: Prescribing and Collaborative Roles.3 Our APA maintains an active and expensive lobbying program in order to defeat prescriptive authority legislation as it surfaces yearly in dozens of states. It may be time for us to reconsider whether this is money well spent. In my opinion, our battle against psychologists prescribing represents a short-sighted attempt to defend our professional turf at the expense of our primary responsibility, which is enhancing our patients' access to high-quality care.

Dr Carlat is associate clinical professor of psychiatry at Tufts University School of Medicine in Boston and editor in chief of The Carlat Psychiatry Report--a monthly newsletter on psychopharmacology. The Carlat Psychiatry Blog (www.carlatpsychiatry.blogspot.com) is consistently ranked as one of the 10 most influential health blogs. Dr Carlat is also a regular contributor to "The Couch In Crisis" blog on www.psychiatrictimes.com where this commentary is posted.